Patients requiring wound care can belong to any age group and are found across all areas of health care: in nursing homes, health centres, inpatient services or at home (Guest et al, 2015). Holistic wound care draws on the skills of a broad range of healthcare disciplines but depends most on nurse-led assessment and treatment (Guest et al, 2015). Nurses are central to ensuring optimal patient outcomes, positive experiences and the best use of resources for people with wounds (NHS England, 2016). To deliver on these triple aims nurses are required to understand types and causes of wounds and their assessment (Adderley et al, 2017), the evidence base which supports nursing care, and the physiology of wound healing (Fletcher and Anderson, 2013).
For nurses, wound management can be challenging: wound healing consists of a series of interrelated processes dependent on several factors that impact on the rate of healing. Wound care should be evidence based but, as Chapman (2016) states, reliable clinical evidence to support best practice is lacking.
Healing of an open wound is defined as a ‘process by which damaged tissue is restored to normal function’ (Worley, 2015: 746). Three physiological processes are involved:
Types and causes of wounds
A wound is defined as any injury or damage to the integrity of the skin (Dealey, 2012). This damage can be a consequence of traumatic injury by mechanical, physical and/or chemical impact, either intentional, as in a surgical incision, ischaemic due to a lack of sufficient blood supply (e.g. an ischaemic diabetic foot ulcer) and/or pressure, as in a sacral pressure ulcer (Dealey, 2012).
The nursing assessment of a wound should include identification of its underlying cause(s). Some wounds result from a combination of factors. For example, an arterial leg ulcer may start as a traumatic physical injury to the lower leg that does not heal due to mechanical damage and which might include narrowing or occlusion of the peripheral femoral arteries. The reduced blood supply to the tissue means that the injured area receives inadequate oxygen and nutrients, so that the wound does not heal: a combination of physical trauma, mechanical issues and ischaemia has caused the wound.
Wounds may, consequently, be classified as either acute or chronic (Worley, 2015). An acute wound is associated with trauma, immediate injury or surgery, with the resulting skin damage progressing through the healing phases. In a chronic wound the skin remains open and does not progress through the healing phases as expected.
Four interrelated phases in wound healing (Box 1) commonly progress in a continuous rather than a discrete manner (Fletcher and Anderson, 2013).
| Phase I | Haemostasis (minutes) |
| Phase II | Inflammation (1–5 days) |
| Phase III | Proliferation or reconstruction (3–24 days) |
| Phase IV | Maturation or remodelling (21 days onwards) |
Awareness of the time periods associated with each phase is important, since they are dependent on a patient's overall state of health. If that is compromised by underlying morbidity, poor nutrition and/or infection, the healing process will be prolonged and the individual healing stages may take longer.
Phase I: haemostasis (a process that lasts minutes)
At the time of injury, the wound bleeds and the cavity fills with blood. Plasma proteins initiate platelet aggregation and the formation of a platelet plug. The clotting cascade in turn initiates a fibrin clot that strengthens the platelets' clot formation to establish haemostasis (Worley, 2015). If a patient is on anticoagulation therapy, such as aspirin or low molecular weight heparin, then bleeding may be prolonged and the first requirement is to stop the bleeding by applying direct pressure.
Phase II: inflammation phase (lasts 4–5 days)
Inflammation is an important part of the body's natural response to injury. It is characterised by symptoms that we associate with acute injury, such as pain, swelling, heat and redness (Dealey, 2012). Healing is delayed when there is a disruption to the inflammatory response, which may be caused by factors including, for example, ongoing foreign material in the wound, wound cleansing causing disruption to the wound bed and/or the presence of infection. In addition, poor nutritional status will delay healing because of the energy and nutritional resources needed to drive the inflammation phase on to the next healing stage. Effectively, wounds can become stuck in the inflammatory phase: an acute wound may become chronic and disabling for patients, as in venous leg ulceration.
Phase III: proliferation or reconstructive phase (lasts 3–24 days)
Phase III is marked by evidence of granulation tissue in the wound, which appears as visibly pink tissue, or by a change in wound shape. Often this phase can overlap with phase II; or, different parts of the wound may display different phases, so that some parts show evidence of granulation tissue and others sloughy tissue. An example of this may be a patient with a sternal incision after coronary artery bypass graft (CABG) surgery. Often, by day 10 to 14, the proximal aspect of a wound will be showing signs of proliferation and reconstruction, whereas the distal portion can appear inflamed, red and exuding serous fluid—all signs of continued inflammation.
Phase IV: maturation or remodelling phase (last from 21 days onwards)
Potentially lasting for more than a year, phase IV marks the return of the skin to normal function. It is characterised by epithelialisation and maturation (Dealey, 2012). For maturation to commence we have to see granulation tissue in the wound and, in the case of a wound healing by secondary intent, this commonly happens from the wound bed upwards and may take a prolonged period, perhaps years. As epithelialisation is established the wound tissue is remodelled by the deposition of collagen fibres (Worley, 2015).
The process of wound healing is not linear and, as illustrated in Box 1, different parts of a wound might be at different stages. A wound may progress from phase II to phase III only for an infection to result in the wound returning to phase II. Determining which phase of healing a wound has reached is an important aspect of its ongoing assessment.
Wound care assessment
Wound assessment helps determine baseline wound information to support decision-making on the selection of appropriate dressings (Worley, 2015). However, currently there is no agreed approach to assessing wounds in the UK (Coleman et al, 2017) and consequently there is concern about unwarranted variation in chronic wound care (Adderley et al, 2017).
As part of NHS England's (2016) nursing and midwifery strategy Leading Change, Adding Value there is ongoing work to develop a wound assessment minimum data set (Coleman et al, 2017). Current thinking on the data needed for a wound assessment is a consideration of six domains:
Delivering evidence-based wound care
The real world of practice demonstrates that, commonly, wound care is a nurse-led discipline (Guest et al, 2015). Therefore nurses need to make informed choices about treatments in partnership with their patients. In wound care this is not as straightforward as it may at first appear, with a plethora of available treatments and dressing options (Chapman, 2017). When faced with this confusion it is good to reflect on a few basic principles and be aware that evidence-based practice (EBP) is not solely dependent on the best available research evidence. EBP in nursing includes patient experience and preferences, and the experience and knowledge of the nurse, to ensure delivery of the most effective care (Lindsay, 2007).
Cleansing the wound
The function of wound cleansing is to prepare the wound bed and create an optimum healing environment (Worley, 2015). It should not be assumed that cleaning a wound is always required and, indeed, in certain circumstances it can be detrimental, damaging newly formed granulating tissue and precipitating a drop in wound bed temperature, both of which may set back healing (Dealey, 2012; Worley, 2015). If a wound is to be cleansed the recommended products are 0.9% saline (common for surgical wounds) and tap water (common for chronic wounds). The use of topical antiseptics, such as povidone iodine in pressure ulcers and leg ulcers, is not supported by research evidence, with no benefit demonstrated despite the persistent use of these products in practice (Chapman, 2016).
A practical approach, therefore, is to advocate careful wound cleansing in acute wounds using sterile 0.9% saline, as part of a nurse's overall assessment of the wound; and, in chronic wounds, with body temperature tap water. This provides an opportunity to assess the wound close up and support patient comfort and relief (for example, if a patient is anxious about wound odour or exudate).
Dressing a wound
Deciding on what topical dressing to apply to a wound bed is another area of much debate and discussion in the nursing literature, with little research to support practice. The lack of EBP leads to wide variation in practice between individual nurses and to inconsistencies in wound dressing over the course of treatment. A recent review by Norman et al (2018) was unable to demonstrate that dressings or topical agents offered any beneficial effect on healing, highlighting the challenges of clinical decision-making. Since the evidence base is so poor, some basic principles of wound dressing provide the best guidance on what to use, and when.
Table 1 provides some principles to adhere to when dressing a wound to act as a guide to decision-making.
| Occlusive dressings form a barrier to bacteria, maintain a consistent temperature and ensure stable wound pH, while allowing gaseous exchange |
| A dressing must be able to stay in place for a sufficient period of time to avoid unnecessary disturbance to the wound bed, so absorbance is an important factor when caring for an exuding wound |
| It is important to consider patient comfort when wearing, and on removal of, a dressing. On removal the dressing should not cause damage to the surrounding skin |
| Dressings ought to be cost-effective: they should be chosen from those listed in an NHS Trust wound care formulary. Information on costs of dressings is included in the British National Formulary (Joint Formulary Committee, 2019) |
| The wound-care product should reflect the wound assessment and treatment plan and wound healing stage, e.g. whether or not there is a requirement for debridement, treatment of localised infection |
Further information on different types/classifications of wound dressing is available in the British National Formulary (Joint Formulary Committee, 2019) available at: https://bnf.nice.org.uk/wound-management/.
Pain management
The presence (or absence) of wound pain should be assessed and recorded (Fletcher and Anderson, 2013). In addition, it is recommended that a record is kept of the frequency and severity of wound pain (Coleman et al, 2017). As nurses, we may be more aware of the association of an acute wound with pain than we are with a chronic wound, but wound pain and discomfort are also very much part of the patient experience of living with chronic leg ulceration (Xiaoli and Ryan, 2017). Nurses should be sensitive to wound pain so that they can better anticipate patient problems.
Pain is an indication not only of patient comfort and wellbeing but also of what is happening in the wound. Pain is a symptom of infection that requires assessment and, if associated with other symptoms, such as an increase in exudate, change in exudate colour, odour, delay in healing and/or swelling to surrounding tissue, the wound should be swabbed (Dealey, 2012). It is important to remember that, although all chronic wounds are colonised with bacteria, this is not the same as the wound being infected (Dealey, 2012). Bacterial colonisation of chronic wounds is not associated with a delay in healing. In contrast, bacterial colonisation of an acute wound can initiate infection and this infection can be localised or systemic (Fletcher and Anderson, 2013). Table 2 outlines the signs of wound infection and the difference between the signs of acute and chronic wound infection.
| Surgical wound, burn or traumatic injury—acute wounds | |
|---|---|
| Localised symptoms: confined to margins of the wound | Systemic symptoms: spreading to tissue or organs beyond the margins of the wound with erythema, swollen lymph nodes and/or wound breakdown |
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In addition to signs of localised infection you may observe: physiological changes including a drop in blood pressure (BP) <90 mmHg, heart rate >130 per minute and respiratory rate >25 per minute. These are known as sepsis red flags and should trigger an early warning assessment (UK Sepsis Trust and Royal College of Emergency Medicine, 2016) |
| Pressure ulcers, arterial or venous leg ulcers, diabetic foot ulcers—chronic wounds | |
| Localised symptoms: pain either new or an increase in the pain experienced | Systemic symptoms: alongside localised symptoms the wound has broken down and redness extends beyond the wound margins |
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Malaise and deterioration of the patient in terms of a high or low temperature, drowsiness or confusion. Wound exudate or blood evident through dressings or bandages |
Knowing when to refer patients for specialist advice
Deciding when to seek specialist advice and support on managing a patient with a wound, is an important aspect of clinical decision-making. Local NHS trusts in England and health boards in Scotland will have specialist services in tissue viability and/or leg ulcer management (nurse-led leg ulcer clinics) and produce guidelines for referral and advice on how to refer and seek support. Being aware of local policy is part of the skill in deciding when to seek help for a patient. Specific criteria, or things to look out for, which should promote referral, depend in part on the aetiology of the wound. Table 3 explains different wounds and when referral is important.
| Traumatic wounds | Non-healing burns, or lacerations, including self-inflicted lacerations |
| Leg ulcers |
|
| Surgical incision |
|
| Pressure ulcers | Grade 3 and 4 pressure ulcer |
| Fungating wound | Associated with increasing pain, odour or bleeding |
| Diabetic foot ulcer | Podiatry services should be involved in the care of all diabetic foot ulcers but specialist tissue viability support may be need in addition if the diabetic foot ulcer is non-healing |
The case study (Box 2) further highlights the importance of seeking specialist tissue viability advice at the most appropriate time and when faced with a challenging situation that, despite taking preventive measures, results in ongoing skin breakdown, in this case at the end of life.
Psychological support for people with wounds
Wounds have a psychological as well as physical impact on people and as part of a patient-centred assessment nurses should consider the impact of living with a wound, irrespective of the length of healing time. In turn, being aware of the psychological impact of a wound helps nurses to provide more sensitive care. Nurses should particularly assess for:
Frustration and depression have also been associated with the experience of living with leg ulceration (Xiaoli and Ryan, 2017). Overall, the negative impact of a wound on an individual's psychological wellbeing is significant and, potentially, as oppressive as the wound itself.
One positive approach to promoting awareness of psychological wellbeing in our daily practice is to consider flipping the conversations nurses have with their patients from ‘What's the matter with you?’ to ‘What matters to you?’ and ‘who matters to you?’ (NHS England, 2016). These questions help to support a patient-centred approach to decision-making; patient involvement in care is an important element in evidence-based care (Byatt and Chapman, 2018).
Summary
This article has highlighted some key considerations in the care and support needed for patients with wounds, both chronic and acute. Using an evidence- and practice-informed approach, it has drawn together current ideas that can inform our knowledge base. It has highlighted current research and gaps in evidence but also areas where new ideas, such as those promoting an agreed UK minimum data set on wound assessment, are being proposed.
Finally, the author argues that nurse-led wound care would benefit from asking, listening to and doing what matters to patients, providing care sensitive to the priorities, hopes and fears of people living with a wound.